Ryan was telling me about the rage he sometimes feels when people get into his space, or “impinge” on him, linking it to the trauma of a forceps birth and spending his first weeks of life in an incubator, tubes stuck into his head.

He also feels enraged when he enters a crowd with too many people around him. Upon entering Walmart, and seeing all the other shoppers, the thought will come into his head, “I’d like to kill someone.”

The rage seems to come up in response to an impingement from the outside that feels threatening.

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Since the beginning of our work together, I’ve noticed that David escapes from being a client by becoming the person who instead “dispenses wisdom,” as he has described it. I’ve tried to talk to him about how he uses this posture to keep me at a distance, becoming a sort of therapist himself.

I’ve been watching cautiously to see where this would lead us. His difficulty bearing need and dependency seemed clear, but I’ve also wondered whether feelings of envy for me as his therapist might also be in the background.

Last Friday, the envy came to the fore – although I didn’t quite see it coming. During session, I was focusing on the way he goes from feeling unbearably small to becoming too big, all at once. He took issue with every remark I made; he became increasingly angry and contemptuous in his manner toward me until finally, by the session’s end, I had become a worthless, incompetent therapist he despised.

Only at the end did I realize I should have been focusing on this process all along. I did what I could in the final minutes to describe what had happened between us. Later that day, I received an email from him, extremely hostile and contemptuous in manner, telling me he wanted to take a month off to try something different.

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Now that I’ve nearly finished my book on defense mechanisms, I’m wondering what to do next. I’ll continue with my book on shame and the defenses against it, but I’d also like to work on something more interactive, involving visitors to this and my After Psychotherapy site.

The project I have in mind would last about a year and eventually evolve into a book. At the beginning of each month, I’d post an exercise in a separate section of my personal website. During that month, participants would independently undertake the exercise, then share their responses with one another as comments to the posted exercise — a kind of virtual group therapy.

I would also respond to and engage in the conversation. Participation should involve no more than 5-6 hours per month.

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Now that I’ve mostly recovered from the last few stressful weeks, I’m able to see more clearly how my stress affected my behavior and emotional presence during sessions. I like to think I’m more self-contained than I obviously am; recent experience has shown me otherwise.

The first indication was the email I received a few weeks ago from Adrienne after one of our sessions. She didn’t mean to be intrusive, she said, but was I all right?

Amidst the end-of-school-year chaos, I’d been feeling stressed. I thought first about asking what she’d noticed, but felt that would be a deflection. So I wrote back and briefly told her the truth: that there were a lot of things going on at the moment, most of them good, but that all in all, it felt like a lot and I was feeling a bit under stress.

I also told her that I thought she was afraid I would fall apart or drop her as a result, as everyone else in her life has always done.

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Neil brought in a dream this week. He and his wife Ellen are somewhere exotic, on an island or maybe in a jungle. Everything has been carved in stone — buildings, statues — and he talked about the interesting rock faces and their angles.

“I dreamed it all in color,” he said, “and that’s unusual for me.” He and Ellen were holding hands, which even in the dream, he thought was odd (given their emotional distance). When I asked if the dream brought anything to mind, he told me that he and Ellen had gone to a gallery over the weekend and saw some interesting sculpture. He thought about buying something for their home, as they used to do, but then he felt, “Why bother?” It would only stir up trouble, meaning the struggle over whose taste would prevail. He didn’t want to go there.

I had many ideas about the dream but no conviction as to any of them. I waited. Neil went on to say he’d been very “self-destructive” this past week. It seemed an unlikely description — I don’t think of him as “self-destructive” — so I asked him to fill me in.

On impulse, Neil told me, he’d decided to fly to Las Vegas with a friend where he stayed up all night and drank so much he wound up vomiting. He surprised himself. He hadn’t stayed awake all night in many years; then to be in a public rest room, feeling the room spin, about to be sick. He felt much better after he’d thrown up. When I asked why he’d gone to Vegas, he told me he felt he just “had to get away.” He couldn’t stand it any more.

After the trip, he felt better able to go back to his routine.

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In session with Naomi, we discussed her ongoing moral dilemma about whether to disclose. She vacillated between an agonizing sense of guilt for occasions in the past when she hadn’t been honest, to a dry-eyed cynicism in which she’d argue that she might as well go on hiding the truth because she couldn’t undo the past.

“I realize that I’m lying to myself. I can hear it, but I don’t know what else to do.”

I offered a couple of suggestions and she looked at me scornfully. “That’s never going to happen,” she scoffed. Her plight felt hopeless; no solution seemed possible.

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I’ve been thinking all week about why some people emerge from a horrendous childhood with hope intact. Given the serial abandonment and sexual abuse, it’s astonishing that Adrienne has any hope whatsoever that someone might care about her.

Why do some people have the ability to recognize goodness when they see it, to cleave unto it for dear life? Why do others never seek help, or when they find it, so easily let go? From my experience, it doesn’t necessarily have to do with the degree of illness. Some of the most troubled clients I’ve worked with over the years have been the most able to value the work and stick to it, despite the hostile and destructive feelings they brought to session.

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Both of my clients who had received a diagnosis of ADD prior to starting therapy and are now taking meds continue to help me understand the psychological origins of this difficulty.

Later in a session, when talking with one patient about how distracted he gets and the ways he procrastinates, I made the parallel: his urge to “move on” from guilt or remorse, putting those feelings out of his mind, resembles the way he “moves on” when he comes up against boredom or frustration.

When I thought about how upset he looked at the beginning of our session — and how rarely he brings much emotion into our work — I realized there’s a lot more pain than I had thought, but that he distracts himself from it so effectively that the pain doesn’t seem to exist.

Distraction as a mechanism of psychological defense; as a “habit of mind,” so to speak, it clearly bears on his ADD symptoms.

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Alan talked in session about his disappointment over the job interview, odds that he won’t get an offer, and feeling “depressed” about it. We’ve discussed depression before but something about what he was saying felt different this time.

He mentioned attempts to rouse himself into action, then sinking back into lethargy. At one point, he was lying on the couch, then got up to clear off his desk. Alan had been neglecting that particular chore for a very long time: his desk was dirty and stacked with old papers, books, cups, etc. He described it as a complete mess. He did his best, then fell back onto the couch, feeling despondent about his future.

The messy, long-neglected desk jumped out at me from all the other details in the session; I felt the little mental “click” that happens when you suddenly understand something in a new way.

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I’ve now uploaded the third installation in my series on psychodynamic psychotherapy, which you can access through the video frame below. This one covers early manifestations of the transference and includes a lot of examples from recent sessions in my practice.

It’s a useful counterpart to my earlier post on the subject, fleshing out the ways that an understanding of the transference can shed light on a person’s “outside” relationships and internal dynamics.

Can I ask a favor? I know that everyone dislikes receiving endless email notifications from all the websites we visit, but the number of people who subscribe to my channel has an impact on my standing in the YouTube community and how my channel ranks; if you watch the video and like it, would you mind subscribing? Many thanks.

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